A Care Coordinator at Complete Health will chronic care management, health education and other support services to at-risk patients.  He/She will support the development of care plans, appointment scheduling, referral processing, and medication management. The incumbent will engage patients and their families for disease management and education sessions to promote positive behavioral modifications. He/she will also provide basic social services, application assistance, and advance care planning to patients, as needed. Under the direction of a Lead RN Care Manager, will provide transition of care services to patients being discharged from post-acute settings; such as hospitals and skilled nursing facilities. The incumbent will be responsible for ensuring billing and documentation is complete for chronic care management for eligible patients. 

Minimum Qualifications

A general knowledge of primary care clinics and medical terminology.  Competency in prevention strategies and care planning for patients with comorbidities (chronic health conditions, behavioral health and substance abuse).     Experience in care coordination, health education, patient engagement or social services. Knowledge of hospitals, specialists, and ancillary health services throughout the assigned community. Interacts with respect and in a professional manner with patients, staff and external customers. 

• Experience: 2 to 3 years professional experience working in a primary care or post-acute setting OR 2 to 3 years of patient navigation, referral management or health education experience. 

• Additional skills: Experience in implementing and billing chronic care management (CCM) and/or transitional care management (TCM). Knowledge of legal and ethical standards for the delivery of primary care.  Strong computer skills with knowledge of Microsoft Office products.  Excellent verbal and written communication skills. Able to work independently and in a multidisciplinary team. Able to effectively utilize an electronic health record to document all patient encounters.   

Education: Completion of an accredited Medical Assistant program OR Bachelor’s degree in Sociology, Social Work, Health Education or related field.

Key Responsibilities 

• Manages a caseload of medium to high acuity patients
• Provides a minimum of 14, 30-minute calls per day
• In collaboration with a PCP, creates and modifies care plans and associated goals
• Assists patients with appointment scheduling, referral processing, prescription filling, and other directions from the PCP
• Under the direction of the RN Care Manager, provide supplemental to support for transitions of care
• Facilitates reminder calls for appointments, labs, and outstanding quality improvement measures
• Provide basic health education and disease management sessions to support positive behavioral change among patients and their care givers
• Collaborates with skilled nursing facilities, hospitals, and ancillary health services to support continuum of care 
• Documents the appropriate criteria for chronic care management (CCM), transitional care management (TCM), and behavioral health integration (BHI) among eligible patients
• Reviews care plans, patient charts, and other health information for the purposes of making acuity recommendations 
• Completes telephonic campaigns for annual wellness visits, health risk assessments, and other quality improvement measures
• Attend utilization management, payer, and physician meetings for updates; as needed
• Other tasks as assigned